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60.3 – Optional Involuntary Disenrollments 42 CFR §§ 422.74(b)(1), 422.74(c), 422.74(d)(1)–(3), 423.44(b)(1), 423.44(c), and 423.44(d)(1)– (2)
If a plan adopts an involuntary disenrollment policy, it must be applied consistently to all enrollees.
Plans may disenroll an individual if: • Premiums are not paid on a timely basis (§ 60.3.1); • The enrollee engages in disruptive behavior (§ 60.3.2); or • The enrollee provides fraudulent information on an enrollment request, or permits abuse of an enrollment card (§ 60.3.3)
In situations where the plan disenrolls the individual involuntarily for any of the reasons listed above, the plan sends a notice of the upcoming disenrollment (must be provided to the individual before the disenrollment is submitted to CMS) with the following: • The reason the organization is planning to disenroll the individual; • The effective date of the individual’s disenrollment; and • The individual's right to a hearing under the plan's grievance procedures.
60.3.1 – Failure to Pay Premiums Section 504 of the Rehabilitation Act of 1973; 42 CFR §§ 422.74(b)(1)(i), 422.74(c), 422.74(d)(1), 422.74(d)(2)(c), 423.44(b)(1)(i), 423.44(c), 423.44(d)(1), 423.286(d)(3)
When an enrollee fails to pay the monthly basic and/or supplementary plan premiums, including any Part D late enrollment penalty, on a timely basis, the plan can opt to choose the following:
MA plan • Do nothing (i.e., allow the member to remain enrolled in the same premium plan). • Disenroll the member after a grace period and proper notice. • Reduce the member's coverage if the member fails to pay the premium for optional supplemental benefits, but the member pays the premium for basic and mandatory supplemental benefits ("downgrade" coverage). Part D plan • Do nothing (i.e., allow the member to remain enrolled in the same PDP). • Disenroll the member after a grace period and proper notice.